Medicare Paid $171 Million for Ophthalmology Services Flagged by OIG for Questionable Billing

Tuesday, October 27, 2015

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

According to the Department of Health and Human Services Office of Inspector General (OIG), Medicare paid a total of $171 million for ophthalmology services that now warrant further scrutiny. OIG flagged various providers as maintaining questionable billing practices for services rendered in 2012. The services billed for and flagged as questionable include the diagnosis and treatment of wet age-related macular degeneration (wet AMD) and complex cataract surgery.

Questionable Does Not Necessarily Mean Fraudulent.

OIG utilizes nine measures when considering potential indicators of fraud and abuse. If questionable billing is demonstrated on at least one of these nine measures, then it is flagged for further review. OIG acknowledged that flags for questionable billing do not necessarily mean impropriety has occurred.

In this instance, Medicare paid $6.7 billion to 44,960 providers for wet AMD and cataract-related services in 2012. Approximately 4% of those providers, or 1,726, demonstrated questionable billing on at least one of the nine measures. OIG reported that another 4% of that number of providers exceeded the threshold for two measures and nine providers exceeded thresholds for three, four or five measures.

While these findings do not conclusively establish the commission of fraud, OIG has advised the Centers for Medicare and Medicaid Services (CMS) to review the identified health care providers and take action if necessary.

To read one of our previous blog posts on several illegal business arrangements to watch out for in health care, click here.

Unusually High Levels of Billing for a Specific Service Can Trigger Flags.

While only about 15% of providers demonstrated questionable billing for wet AMD treatments, Medicare payments for these services totaled more than half ($91 million) of all payments associated with questionable billing. Many providers were also indicated in questionable billing for complex cataract surgery. However, the total Medicare payments for the cataract procedures at $39 million was much lower than that of wet AMD treatments.

OIG identified 355 providers with unusually high billing related to the diagnosis of wet AMD costing Medicare a total of $23 million. Another 586 providers were reported with unusually high billing for ophthalmology claims using certain modifiers totaling $18 million in Medicare payments.

The OIG observed that when providers bill for certain procedures at unusually high levels compared to that of their peers, it may be because such services are not medically necessary, thereby indicating possible fraudulent activity. On the other hand, our experience in defending ophthalmologists and optometrists has shown that it might also just be the result of a certain physician being the best around in performing that procedure.

To read one of our previous blog posts regarding intentional misdiagnosing and billing for the performance of unnecessary treatments, click here.

According to OIG's report, and in comparison to the national average of 2.6%, seven metropolitan areas had at least double the percentage of Medicare payments associated with the measures of questionable billing. Miami, Florida made the list as one of the seven areas, along with: Huntington, West Virginia; Vineland, New Jersey; Salisbury, Maryland ; Grand Rapids, Michigan; Fresno, California; and Cincinnati, Ohio.

Furthermore, OIG indicated that $2 million paid by Medicare for ophthalmology services performed, was paid to 821 various providers that were not listed as eye specialists in government databases. OIG asserts that this calls into question the quality and appropriateness of services rendered by these individuals if, in fact, they were not properly trained to perform such services.

Health care professionals should expect to see more Medicare audits now than ever before. This is due in large part to growing efforts to decrease expenditures on entitlement programs. With the expansion of several Medicare fraud detection programs, the government has seen much success in recovering large sums of Medicare overpayments.

The government places an exorbitant amount of trust in health care professionals to provide necessary, cost-effective, and quality care to patients. Payment of claims is based almost solely on what is included in the claim by the signatory physician. The powerful and extreme criminal and civil laws enacted by Congress in response to fraudulent activity is a direct result of the amount of trust invested in physicians by the government. Understandably, breaking that trust results in severe penalties.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

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